Orthotics and Rehabilitative Exercise in the Prevention of Lower Limb Injury

This article was originally published in Current Pedorthics Magazine

In the allied health profession research is important and should always be the cornerstone of any implemented management or treatment plan. Additionally, what we as practitioners find in a clinical setting can be different to what the evidence may suggest, for better or worse. The following article uses a combination of the literature and what I have found clinically works in the prevention and rehabilitation of lower limb injuries.
The prevalence of lower limb injury amongst athletes has been reported to be anywhere between 19-79%. Those numbers alone are astounding and it is no wonder that when researching this topic, I found no fewer than fourteen systematic reviews based on the prevention of lower limb injury. Many of the studies focus on the non-contact based pathologies: metatarsal stress fractures, medial tibial stress syndrome, patella-femoral knee pain, achillies injury and plantar fasciitis – surprisingly lateral ankle sprains, which have been noted as the most common sporting injury outside of non-specific bruising was not highlighted within the systemic reviews, however, this may be due to it being an umbrella term as opposed to a specific pathology.

Treating the whole person and not just the presenting pathology is becoming a necessity of the services we provide. Although in the podiatry profession we specialise in the foot and ankle there is a need to understand the biomechanics of the more proximal anatomy to help identify movements which may contribute or cause a presenting complaint in the patients we see. As such, the way we treat complaints has moved from a seemingly narrow scope of practice to a multi-faceted management strategy, to get the best result for our clients in the shortest amount of time and attempt to prevent any re-injury or secondary injury as a result of detraining.
When trying to prevent injury a practitioner should aim to offload structures identified as being under high loads of stress, satisfactory rehabilitate previous injury, educate the patient on appropriate footwear choices and refer for a strength and conditioning program tailored to their chosen activity.

Footwear
Athletic attire has transformed the sporting world over the last seventy years or so – especially in the footwear category. From waffle-iron pressed rubber to 3D printed one piece uppers the athletic footwear enterprise encompasses scientific evidence, fashion trends and at times bizarre additions that look like they’re out of a back to the future movie.
The evidence available for footwear’s impact of injury prevention is very limited, most circulates around debate of high top vs low cut basketball shoes and lateral ankle sprains – spoiler alert – low cut wins. Using footwear as an injury prevention strategy primarily comes down to taking an accurate patient history and analysis of the movement patterns and demands of their chosen sport. Football boots have a variety of sports they are useful for whether it be Football, Rugby, Soccer or Aussie Rules each of which also has a variety of surface types they may be played on. Tennis and other racquet sports provide similar issue to the practitioner and patient, as do running shoes!
Your safest option when prescribing shoes for the purpose of injury prevention is to make sure the shoe is designed for the activity in mind, that the shoe is of adequate length and width for the individual and that the outsole is designed for the surface it is to be used on. Other than that it’s all about comfort comfort comfort!Orthotics/Offloading
The use of orthotic therapy as a way of preventing injury has always been a hotly debated topic, with the key argument against the use of orthotics being “if the tissues are able to tolerate the stressors being placed upon them, why would you look to redirect or attenuate those forces?” in other words “if it’s not broke, why fix it?”.
That argument now seems to hold less weight with the release of a systematic review and meta-analysis identifying the benefits of orthotics in reducing the presence of common lower limb injury.
Bonanno et al 2016, looked at 16 trials (11 custom orthotics, 7 shocking absorbing insoles) in the prevention of lower limb injury. Their findings indicted that the use of custom orthotic devices in the prevention of lower limb injuries was effective in the case of stress fractures and overall injury rate, however, was not effective in the prevention of soft tissue injuries. Furthermore, the use of shock absorbing insoles was not found to be effective in the prevention of injury.
A previously published systematic review without meta-analysis concluded that custom orthotics were effective in the prevention of lower limb stress fractures and shin splints but not effective in the prevention soft tissue injuries or back pain.

So what does this actually mean for us clinically?

Well, one thing that becomes clear from the research is there is no proven reason for why orthotics work in the prevention of injury. We have an abundance of theories and mechanisms toward their prescription and manufacturing but yet no definite agreement amongst professionals.
I take the approach that the orthotic is only one piece of the puzzle. I use the orthotics or similar devices to offload areas of increased pressure or repetitive stress and move on to other modalities to provide the best outcome for a patient, such as exercise prescription.

Strength and Conditioning
When studying at University the concept of strength and conditioning was not a topic or subject that seemed to be largely taught, or at least not in depth. Despite the over whelming amount of evidence available describing well prescribed and executed exercise programs as being effective in the prevention and rehabilitation of lower limb injuries, there was more focus on diagnosis and identification of contributing factors.
This is where my further study as a strength and conditioning coach has really helped me in a clinical setting. Being able sit down with a patient and map out a sustainable exercise program which best prepares them for the up-coming season or identifying a spike in the patients acute: chronic workload that may have contributed to the injury is a skill I wish more practitioners had available to them.
As previously mentioned, the use of custom orthotics has not been found to be effective in the prevention of soft tissue injuries. Therefore, developing and conditioning those soft tissues is of the upmost importance. When developing a strength and conditioning program for a patient it is important that you have an accurate description of past injury (of any kind) and physical activity levels over the last four weeks, as a minimum.
Rehabilitative exercises should be put in place for any injury which has occurred. Within the rehabilitative process the practitioner should be looking to re-establish proprioceptive awareness, muscle activation and control before increasing the resistance of the exercise and looking to develop strength.
Strength development should be the basis of all sport specific exercise programs. Strength development is a neurological adaption to repetitive force production and as such is the underpinning principle for the development of Power Production (Force x Speed) and Muscular Endurance (Repetitive Force x Time).
Developing a good report with the patient’s sports coach or strength and conditioning coach will really help in creating an understanding of what you wish to achieve as a practitioner and what the coach or club needs from the athlete.
By instigating the use of offloading devices, correct footwear and appropriate exercise program, most of which can be placed back on the responsibility of the patient to comply with, your time as a practitioner can be used to help maintain and improve tissue viability through the use of soft tissue management.

Soft Tissue TreatmentDifferent types of soft tissue treatments have been used to help people’s quality of life and athletic performance for centuries, many of which are still used today. From eastern medicine based practices such as; acupuncture, acupressure, cupping and reflexology to their westernized counter-parts of dry needling, slides & glides and trigger point therapy.
Soft tissue therapy helps an individual relax and prepare for further activity by releasing adhesions within muscle tissues. This in turn can contribute to an increase in a client’s range of motion and a decrease in the muscular inhibition as a result of pain. Additionally, for those who are continuing to train during their rehabilitation process massage may help disposed of by-products and blood pooling.
A multi-faceted and at times multi-discipline approach to patient management should be taken when looking to both prevent and rehabilitate lower limb injury. The use of a number of injury management strategies can lead to a faster and more complete recovery of a patient, setting them up for the season or competition ahead.
Using offloading devices such as custom orthotics, wedging or domes to attenuate forces in areas of high stress can limit the impact of repetitive trauma to an athlete. Simple shock absorbing insoles have been found to have no effect on the prevention of lower limb injury.
A lot of time and effort goes into creating sport specific footwear to help athletes of all levels get an advantage in play as well as trying to protect them from both intrinsic and extrinsic influences which may contribute to injury. This can be seen in something as simple as a lateral forefoot flange on a tennis shoe to interchangeable studs on football boots.
Strength and conditioning training not only prepares an athlete for the physical demands of a sport but the psychological demands as well. Neurological adaptions associated with the movement patterns and physical needs help to improve athlete balance and proprioception.
Previous history of injury to the lower limb is the biggest predictive factor for recurrent or secondary injury to the lower limb. Thus, the adequate and complete rehabilitation of any sustained injury should be a high priority when preparing a patient for future competition. Inhibition of muscle activation due to pain or muscle atrophy as a result of detraining can have a serious impact on the prevention of lower limb injury.

When a patient comes to see an allied health professional for injury management their motivation to address the issue is at its peak, it is important that we take advantage of this motivational factor to get the best compliance from our clients. Although in a single consult we may not have time to put all the modalities discussed today in place, having a number of appointments in quick secession targeted toward the integration of these strategies is paramount to enabling a fast recovery.

Until Next Time

Jackson McCosker
Director/ Chief Editor

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FootNotes Blogging was established by new graduate podiatrist Jackson McCosker in 2014 as a means of motivation to stay up to date with current evidence, clinical practice management, increasing client base and building professional credibility among peers and community organizations at all levels. FootNotes Blogging aims to provide accurate, up to date and well thought out management information in both a professional and entertaining format.
Although evidence based management is promoted within the forum, it should also be noted that much of that published by FootNotes Blogging is subjective in nature and general in suggested management practices. It is recommended that those reading seek one on one medical advice from a medical practitioner or podiatrist before following any advice [as per disclaimer].
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